Surgical interhospital transfer mortality: national analysis

Abstract Background Interhospital transfers of surgical patients are an independent risk factor for mortality. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) aims to improve surgical care through assessment of all cases of surgical mortality. This study aimed to describe common clinical management issues that contributed to interhospital transfer patient mortality. Methods Data for all surgical patient mortality in Australia (except New South Wales) that underwent interhospital transfer between 1 January 2010 and 31 December 2019 were extracted from ANZASM. The surgeons’ reports and assessors’ evaluations were examined to identify clinical management issues. Thematic analysis was performed to develop pertinent themes and subthemes. Results Some 8679 patients were identified over the 10-year period. Of these, 2171 (25.0 per cent) had 3259 clinical management issues identified. Prominent themes were operative design (n = 466, 14.3 per cent), decision to operate (n = 425, 13.0 per cent), medical conditions (n = 344, 10.6 per cent), diagnosis (n = 326, 10 per cent), transfer (n = 293, 10.0 per cent), intraoperative issues (n = 278, 8.5 per cent), inadequate assessment (n = 238, 7.3 per cent), communication (n = 224, 6.9 per cent), delay in recognizing complications (n = 180, 5.5 per cent), coagulopathy (n = 151, 4.6 per cent), insufficient monitoring (n = 127, 3.9 per cent), infection (n = 107, 3.3 per cent), and hospital resources (n = 100, 3.1 per cent). Assessors considered 58.4 per cent of clinical management issues (n = 1903) probably or definitely preventable. Conclusion This study identified 13 themes of potentially avoidable management issues present in surgical mortality following interhospital transfers. Quality-improvement initiatives targeting these areas may improve surgical patient outcomes.


Introduction
Geographical factors of health networks can produce significant discrepancies in the provision of health care between metropolitan and rural hospitals. Interhospital transfers (IHTs) can facilitate the delivery of timely surgical care within large health networks and resolve issues such as lack of appropriate resources at the index location, higher acuity of care requirement, or need for complex multidisciplinary specialist care 1,2 .
IHTs have been demonstrated to be an independent risk factor for increased mortality in many surgical cohorts [3][4][5][6] . These factors can be categorized into patient, disease, and transport factors. Patient factors include older age and lower socio-economic background, while disease factors include level of complexity and severity [3][4][5] . Transport factors that can lead to potential delays in definitive surgical care include method of transportation and distance travelled [3][4][5] . IHT patients have higher in-hospital mortality and healthcare costs, and poorer outcomes than their non-transferred counterparts 6 . Given that IHT is associated with 1 in 13 hospital admissions in Australia 7 and entails considerable cost 6 , it is imperative to ensure that they are conducted effectively to optimize patient benefit.
With its large land area and widely dispersed population, Australia provides an example of a setting within which health networks must overcome geographical issues to provide equitable care to metropolitan and rural centres. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) is a national, independent, peer-reviewed surgical audit overseen by the Royal Australasian College of Surgeons 8 . Since its inception, it has identified major issues for intervention in surgical care of patients by aggregating national surgical outcomes 9 . To highlight potentially avoidable issues and facilitate quality improvement, this study examined 10 years of Australian mortality data on surgical patients who were transferred between hospitals and aimed to identify common clinical management issues that contributed to patient mortality. Highlighting potentially avoided clinical management issues from these deaths could be used as a foundation for future quality-improvement strategies and surgeon education to enhance patient care.
Australian surgeons and 100 per cent of public and private hospitals performing surgery participate in the audit 10 . Since 2010, all fellows of the Royal Australasian College of Surgeons are mandated to participate in the mortality audit and this is required for re-certification 10 . Following notification of the death of a patient for whom a surgeon had cared for, or had significant involvement with, a standardized surgical case form is completed by the treating surgeon and returned to ANZASM 8 . The surgical case form return rate for participating surgeons is 92 per cent 10 . The surgical case form is deidentified and peer reviewed by an independent surgeon from the same specialty, but different hospital, for first-line assessment. If the assessor determines that there was adequate data to provide assessment regarding the quality of care and highlight areas of improvement, then the case is closed, with no further investigation warranted. However, if the first-line assessment determines that the data for assessment are inadequate, or specific aspects of care require further investigation, a second line assessment by an additional independent reviewing surgeon from the same specialty is organized, with the addition of information from the original medical records. The assessor is able to comment on aspects of patient management that may have been improved or contributed to patient mortality, deemed clinical management issues. These were then classified into three levels of seriousness: area for consideration, area of concern, or adverse event 10 . Each clinical management issue was also assessed for clinical impact and preventability. Clinical impact was assessed on a 3-point scale from 'made no difference' to 'caused death of a patient otherwise expected to survive'. Similarly, preventability was assessed on a 4-point scale from 'definitely not preventable' to 'definitively preventable'. The independent assessor's report is provided to the treating surgeon.

ANZASM data extraction
Patient demographics and assessor reports for patients that had an IHT were extracted from the ANZASM database. This included all surgical patient mortality in Australia (except New South Wales) over a 10-year period between 1 January 2010 to 31 December 2019. Cases prior to 2010 were excluded owing to the risk of reporting bias, since participation was not mandatory 8 . Cases in which there were incomplete data were excluded from qualitative analysis and characterization of clinical management issues.

Qualitative analysis
Surgical case form and assessor report data were examined for clinical management issues for all patients. The available narrative reports from second-line assessment and clinical management issues identified by the ANZASM assessors were qualitatively analysed using a thematic analysis technique with an inductive data-driven approach, developed based on methodology described by Braun and Clarke 11 . This method of thematic analysis has been used to examine trends of clinical management issues in patient mortality from ANZASM data in endocrine surgery, neurosurgery, urology, and cardiothoracic surgery [12][13][14][15] . All clinical management issues were analysed regardless of level of seriousness, and each patient case may have contained one or more clinical management issue. Patients were included for analysis irrespective of whether the assessor deemed the death as preventable, as clinical management issues that occur in unavoidable deaths can still provide important lessons.
Two independent authors (I.M., A.N.C.) each reviewed all assessor reports, noting key ideas and issues identified in clinical management issues. Initially, 100 cases were coded by the two authors and an initial coding framework developed in consultation with other senior authors. Discrepancies in the initial coding framework were resolved by discussion among the authors. After finalizing this coding framework, two independent authors (I.M., A.N.C.) coded the data across the entire data set in a systematic fashion, collating data relevant to each code, with overall agreement of 82 per cent. Any discrepancies in the final coding were resolved by evaluation by a third author (A.S.). Following this, the coding framework was collated to construct and define potential themes. The themes were reviewed by the authors to ensure appropriateness in relation to each coded data extract, as well as the entire data set, producing a thematic 'map' of the analysis. After reviewing and refining of the themes within the coding framework, subthemes were explored to develop the finalized thematic analysis of the available qualitative data set.

Results
In

Characterization of clinical management issues
Of the 2171 patients, 3259 clinical management issues were identified that may have contributed to patient mortality. In total, 1433 (66.0 per cent) patients had one clinical management issue identified, 441 (20.3 per cent) had two, 245 (11.3 per cent) had three, 51 (2 per cent) had four, and one patient had six clinical management issues identified (Fig. 2).
In terms of surgical specialty of admission for clinical management issues in IHT mortality, the most common was general surgery (830 patients; 38.2 per cent), followed by cardiothoracic surgery (346 patients; 15.9 per cent), neurosurgery (339 patients; 15.6 per cent), orthopaedic surgery (266 patients; 12.3 per cent), vascular surgery (225 patients; 10.4 per cent), urology (67 patients; 3.1 per cent) and other surgical specialties (85 patients; 3.9 per cent). The proportion of patients with clinical management issue versus total IHT mortality patients sorted by surgical specialty of admission is shown in Fig. 3.
Clinical management issues were graded in terms of seriousness. In total, 1851 (56.8 per cent) clinical management issues were identified as an area of consideration that the assessor believed could have been improved, 999 (30.7 per cent) were an area of concern, and 369 (11.3 per cent) were unintended adverse events or injury caused by medical management which led to prolonged hospitalization, patient impairment, or death. Forty (1.2 per cent) clinical management issues had incomplete data collection for seriousness and were not included.
Clinical management issues were graded for clinical impact to determine whether they contributed to patient death. In total,  Clinical management issues were graded by assessors for preventability. In total, 146 (4.5 per cent) clinical management issues were deemed definitely unpreventable and 1003 (30.8 per cent) were deemed probably unpreventable. Assessors deemed that 1256 (38.5 per cent) clinical management issues were probably preventable and 647 (19.9 per cent) were deemed to be definitely preventable. Altogether, 207 (6.4 per cent) clinical management issues had incomplete data collection for preventability and were not included.

Thematic analysis
Clinical management issue analysis revealed trends in four key domains of patient care: patient evaluation (871 issues; 26.7 per cent), operative (1169 issues; 35.9 per cent), medical management (602 issues; 18.5 per cent), and non-technical (617 issues; 18.9 per cent) (Fig. 4). Key themes identified in the evaluation of patients included diagnostic issues, a delay in recognizing complications, inadequate assessment, and insufficient monitoring. In the operative domain, key themes identified were the decision to operate, operative design, and intraoperative problems. In the medical management domain, prominent themes were inappropriate management of coagulopathy, infection, and patient's additional medical conditions. Finally, prominent themes in the non-technical domain identified were issues in communication, patient transfer, and hospital resource limitations. Subthemes were identified in each major theme ( Table 1).

Discussion
This 10-year analysis of national surgical mortality data identified key issues for IHT patients. Two main groups of patients requiring IHT were identified, both of which are different and therefore clinical management issues represented distinct differences. The first group is emergency IHT (often from the emergency department) due to an unstable patient with a surgical diagnosis that cannot be treated locally. The second group comprises patients that have been diagnosed and are waiting for specialist care unavailable at the index location, such as neurosurgery or cardiothoracic surgery, and receive their initial radiology and work-up in the regional hospital but require transfer to a larger metropolitan service for their definitive management. These may inform clinical modifications at an individual hospital, health network, and broader systems level that could significantly reduce mortality associated with surgical IHTs. Further, the identified themes may facilitate the production of effective quality-and safety-improvement initiatives.
Patient evaluation forms the foundation for recognition of deteriorating patients and transfer of patients to an appropriately resourced hospital. Accounting for over a quarter of all clinical management issues, assessors noted diagnostic challenges, inadequate assessment, a delay in recognizing  Outcomes for these conditions depend on early diagnosis and surgical treatment, and delay in achieving this increases mortality proportional to the time delay. The development and implementation of clear protocols and guidelines for clinical assessment and investigation may reduce the potential for diagnostic error 16 . Clinical pathways for specific emergency high-risk surgical conditions, which identify presenting symptoms and suggest high-yield investigations to delineate between serious conditions, could be used to improve patient safety. A 2010 Cochrane review identified clinical pathway documents that link up-to-date evidence with specific health conditions are associated with reduced in-hospital complications and improved documentation without negatively affecting duration of hospital stay or cost 17 . A recent analysis of IHT patients using ANZASM data found that inadequate clinical assessment resulted in a 49.5-fold increased likelihood of transfer delay 18 , resulting in poorer patient outcomes 4 . Finally, important clinical management issues were identified associated with insufficient monitoring and a delay in recognizing complications. Adverse events are often predicted by observable physiological and clinical abnormalities 19 , and early identification of these signs of deterioration can improve outcomes 20 . Standardized early-warning systems and medical emergency teams have been implemented 21 to address this, and remains an area of ongoing national review and action in Australia 22 . Artificial intelligence algorithms may also have an increasing role in the detection of patient deterioration 23 .
Many operative clinical management issues were identified, with key areas of concern being the decision to operate, operative planning, and intraoperative complications. Most concerns in this group were related to clinical decision-making regarding decision to operate and operative planning. In this patient cohort, during the first operation (1929 patients), the consultant surgeon was responsible for the decision to operate and operative planning in 92 per cent of cases, comparable to the 90 per cent attendance previously reported using national Australian data analysing postoperative deaths 24 . This suggests satisfactory rates of consultant involvement, and achieving a higher rate in Australia may not be feasible with senior registrars performing minor operations in many hospitals 25 . The high proportion of incidents coupled with high rates of consultant involvement may suggest a role for increased consultation among senior clinicians and multidisciplinary team discussions regarding complex patients. Increased use of telehealth services to provide clinical assistance in regional areas may also be of benefit 26 . Finally, intraoperative events were defined as the culmination of surgical technical challenges and other intraoperative complications. This may be thought of as a summation of preoperative factors that preceded the sentinel operative incidents. Additionally, as the vast majority of cases were consultant-led with expected adequate technical expertise, the role of non-technical errors inside the operative theatre requires consideration 27 . Continued education and training for all surgeons in non-technical skills may be beneficial in ameliorating this.
Management of medical issues was present in 18.5 per cent of clinical management issues. Key themes identified were management of coagulopathy, infection, and fluid therapy. Venous thromboembolism management is of specific interest as failure of appropriate prophylaxis may result in death secondary to pulmonary emboli. There has been considerable work in this field to improve patient outcomes, and national guidelines have been developed to promote appropriate practice 28 . The average age in the examined patient cohort was 70 years, with multiple medical comorbidities and heterogeneous medical management issues identified. Data from orthopaedic surgery have identified a co-management model with medical specialties significantly improved mortality following hip fractures 29 . Given the elderly, multi-comorbid and high-risk population of surgical IHT patients, a similar model could be hypothesized to improve patient mortality by holistically addressing baseline medical conditions in addition to the emergency surgical problem. Additionally, higher utilisation of intensive care unit (ICU) resources upon transfer may be beneficial. Insufficient monitoring was a key theme in issues identified in patients who are transferred due to need for higher level of care from patient or disease factors, and these cases may warrant earlier ICU review and support.
Non-technical factors such as communication issues, delays in transfer, and hospital resource limitations accounted for 18.9 per cent of all clinical management issues identified. Good communication is essential for prompt and appropriate  30 . Poor communication has been associated with a greater than sixfold increase in the likelihood of delay in transfer 18 . As such, standardization of information exchange during transfer using a structured checklist may improve interhospital efficiency and patient safety. Widespread use of electronic medical records may also aid in improving communication and handover during transfer; however, the use of a consistent system over multiple institutions remains a challenge. In the Australian state of Victoria all IHTs due to trauma is coordinated through Adult Retrieval Victoria, a centralized retrieval system that has access to the on-call schedule and bed availability of all metropolitan ICUs and can rapidly facilitate a conference call between all the specialists needed for case discussion. Using a centralized retrieval team may help to ameliorate the challenges in communication during IHT, and has been shown to reduce mortality and improve long-term patient outcomes 31  A key strength of the ANZASM assessment is the speed of review of the case information, often the complete medical records, within a matter of weeks after the death 8 . Findings may inform surgical training and clinical education at an institutional level, as well as recommendations and priorities for safety initiatives at a systemic level. Pertinent cases are highlighted regularly online in case review booklets to allow lessons to be communicated among the surgical community and not limited to the treating surgeon or institution 33 . Factors identified and influencing care in the transfer of patients in Australia may or may not be relevant in other health jurisdictions. This large national heterogenous cohort of patients includes transfers of varying urgencies, distances, settings, and demographics. This may offer potential comparisons to international settings and services. The data collected have been self-reported by the treating surgeons, which increases bias. Additionally, assessors themselves may also introduce their own degree of bias. The effect of this bias is minimized as assessors were independent and blinded. It is possible that not all mortalities were included due to reporting bias in ANZASM; however, this is likely to have been minimized due to the high surgeon participation (99 per cent) and return of standardized case forms (92 per cent) for review and assessment. Furthermore, second-line assessment occurred in 42.0 per cent of cases allowing direct case notes review, which may have limited reporting bias of the treating surgeon. Missing data from the ANZASM may have introduced bias. This was limited in the characterization of clinical management issues as only between 1 and 7 per cent of cases had missing variables. Since all assessments of clinical management issues were performed by surgeons without input from other members of the patient's clinical team, there may be a skew towards operative issues. Potentially, different clinical management issues may be identified if cases were to be reviewed by the medical teams or anaesthetists. As the study only encompassed mortality data and not all IHT patient data, a clear denominator for clinical management issues cannot reliably be established. Therefore, definitive prevalence values cannot be ascertained. A limitation of qualitative data analysis is that thematic generation may introduce researcher bias. Attempted minimization of this occurred by having multiple researchers examine each clinical management issue and discrepancies reviewed by a separate, independent researcher.
There remains a paucity of research examining management issues present in surgical deaths following IHT. This study analysed a large patient cohort of surgical deaths across a 10-year period over various surgical specialties in both the public and private healthcare sectors in Australia. Thirteen themes of potentially avoidable management issues present in surgical mortality following IHTs were identified. Quality-improvement initiatives targeting these areas may improve surgical patient outcomes across metropolitan and rural systems of care. Future research into this topic may involve production of a transfer safety checklist to ensure safe and effective transfers occur in addition to having a standardized method for auditing transfer performance.